Thyroiddiseaseinelderly-3.pmd

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1 DEFINITION
2 HYPERTHYROIDISM
& TREATMENT
What do the following patients over the age of 60 years have incommon? Hyperthyroidism in the older patient
1) A 72 year old grandmother with “fluttering of the heart” and vague As in all hyperthyroid patients, if there is too much thyroid hormone, every function of the body tends to speed up (see 2) An 80 year old man with severe constipation who falls asleep However, while the younger patient often has multiple symptoms related to the overactive thyroid, the elderly patient may only have one or twosymptoms. For example, patient number 1, above, experienced only a 3) A 63 year old retired grade school teacher who has lost strength sensation of her heart fluttering, and some chest discomfort on climbing in her legs, causing difficulty in climbing stairs and in carrying stairs. Other patients may also have few symptoms, such as patient number more than 3 books at a time; she has recently lost 15 lbs in spite 6, whose main symptoms are depression and tremor. Such a patient may withdraw from interactions with friends and family.
4) A 75 year old grandmother who has developed difficulty Treatment of the older patient with hyperthyroidism
swallowing and a dry cough, accompanied by hoarseness, weightgain, and dry, itchy skin; As with younger patients, treatment of hyperthyroidism in the older patientincludes antithyroid drugs and radioactive iodine (see 5) A 78 year old retired musician whose family complains because Surgery is rarely recommended due to increased operative risks in the older patient. While Graves’ disease is still a common cause of 6) An 84 year old very energetic seamstress in whom a hand tremor hyperthyroidism, toxic nodular goiter is seen more frequently in the older has caused her to give up her favorite activity. She is so depressed patient. During therapy, the effects of change in thyroid function on other that she will not eat, and she has lost 12 lbs in the last 4 months.
body systems must be closely monitored, due to an increased likelihoodof co-existing cardiac, central nervous system and thyroid disease in older All of these patients have abnormal function of their thyroid glands.
patients. Most often, thyroid function is brought under control first with Patients 1, 3 and 6 have hyperthyroidism, that is, excessive production antithyroid drugs (propylthiouracil or methimazole (Tapazole®)) before of thyroid hormone by their thyroid glands. Patients 2, 4 and 5 have definitive treatment with radioactive iodine.
hypothyroidism, or reduced production of thyroid hormone. Whilesome of the symptoms of hyperthyroidism and hypothyroidism are During the initial phase of treatment, doctors will observe cardiac function similar to those in younger patients, it is not uncommon for both closely due to the effect of changing thyroid hormone levels on the heart.
hyperthyroidism and hypothyroidism to be manifest in subtle ways Symptoms of hyperthyroidism may be brought under control with in older patients, often masquerading as diseases of the bowel or adjunctive medications, such as beta-adrenergic blockers (propranolol heart or a disorder of the nervous system. An important clue to the [Inderal®], metoprolol [Lopressor®]), which are often given to slow a presence of thyroid disease in an elderly patient is a history of rapid heart rate, although they must be given with caution in the patient thyroid disease in another close family member such as a brother, with co-existing congestive heart failure and the dose should be reduced This page and its contentsare Copyright 2005 HYPERTHYROIDISM CONTINUED
once thyroid function is controlled in the normal range. Symptoms and Treatment of the older patient with hypothyroidism
signs of angina pectoris and heart failure must be treated in tandem with As with the younger patient, pure synthetic thyroxine (L-T ), taken the treatment to bring thyroid function under control.
once daily by mouth, fully replaces the function of the thyroid gland Once thyroid function is maintained in the normal range with oral and successfully treats the symptoms of hypothyroidism in most medication, the doctor and patient can make a decision on definitive treatment with radioactive iodine together. In general, an attempt is made treatment of the older hypothyroid patient must take into account that to render thyroid function either normal or low in an elderly patient full thyroid hormone replacement need not take place rapidly, and in treated with radioactive iodine. Treatment of an underactive thyroid fact may put stress on the heart and central nervous system if condition (hypothyroidism) is usually more straightforward than the accomplished too quickly. Rather, hormone treatment is usually problem of recurrent hyperthyroidism in the older patient, because of begun slowly with a partial daily dose, in order to allow the heart the effect hyperthyroidism can have on the heart, as indicated above.
and central nervous system to adjust to increasing levels of thyroidhormone. The patient and family members must be aware of apossible increase in angina, shortness of breath, confusion and change 3
in sleep habits, and notify the prescribing physician if these occur.
HYPOTHYROIDISM Treatment may therefore begin with L-T in a dose of 25 to 50
& TREATMENT
micrograms daily, and the dose increased in steps every 4-6 weeks untilthe laboratory tests show a gradual return of blood thyroid hormoneand thyroid-stimulating hormone (TSH) levels to the normal range.
Hypothyroidism in the older patient
Older patients with no evidence of heart disease, stroke or dementiamay be started on larger doses (for example, half of the anticipated Hypothyroidism is very common in patients over 60 years of age and full replacement dose) and proceed to full hormone replacement more quickly. In patients who experience increased angina pectoris, patients in nursing homes may have undiagnosed hypothyroidism. Unlike symptoms of congestive heart failure, or mental changes such as symptoms of hyperthyroidism, the symptoms of hypothyroidism are very confusion will need to have their dose of L-T decreased, then more non-specific in all patients, even more so in the older patient. As with gradually increased over several months’ time.
hyperthyroidism, the frequency of multiple symptoms decreases in theolder patient. For example, memory loss or a decrease in cognitive functioning, often attributed to advancing age, may be the only symptoms Thyroid disorders have no age limits; indeed, hypothyroidism is clearly of hypothyroidism present. Symptoms and signs of hypothyroidism may more common in older than in younger adults. Despite the increased include weight gain, sleepiness, dry skin, and constipation, but lack of frequency of thyroid problems in older individuals, physicians need these symptoms does not rule out the diagnosis. To make this diagnosis a high index of suspicion to make the diagnosis since thyroid in the elderly patient, a doctor often needs a high index of suspicion.
disorders often manifest as a disorder of another system in the body.
Clues to the possibility of hypothyroidism include a positive family history Older patients with thyroid disorders require special attention to of thyroid disease, past treatment for hyperthyroidism, or a history of gradual and careful treatment, and, as always, require lifelong follow- extensive surgery and/or radiotherapy to the neck.
A decision to treat the patient with a new diagnosis of hypothyroidismwill rest on several factors, including whether the patient is symptomatic ADDITIONAL PATIENT RESOURCES
from hypothyroidism, or just has an elevated thyroid-stimulating hormone WWW.THYROID.ORG
(TSH) level. In the case of the latter finding, many doctors will repeat the test in 3-4 months and elect to begin thyroid hormone replacement when the TSH level stays above the normal range. The presence or absence, and severity, of thyroid-related symptoms and co-existing diseases such as coronary artery disease or heart failure will determine the dose of thyroid hormone replacement that is given.

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